Smart Thinking blog

Framing the issues

When access to healthcare isn't access

Insurance for everybody! Well, that's what President Trump said in mid-January when he was asked about his plans for repealing and replacing the Affordable Care Act. And when his nominee for the post of Health & Human Services, Tom Price, was asked specifically about this during his senate confirmation hearings, he stated that his goal was to 'to ensure that all Americans have the opportunity to gain access to insurance coverage'.

Two very different things, no? The almost-nominee-for-the-democratic-party, Bernie Sanders took Mr Price to task and berated him like a schoolchild saying “'has access to' does not mean that they are guaranteed health care”. He went on further to say: “I have access to buying a $10 home, I don't have the money to do that.” But wait a minute. Is Bernie Sanders right in drawing that metaphor? Let's be clear about the fact that equating the opportunity to gain access to insurance coverage is not nearly the same thing as having access to buying a $10m home. Not even close. And most Americans don't have access to buy a $10m home anyway. With rigorous screening of potential buyers of properties in the seven figure range (let alone the eight figure range) routinely taking place, there is no way that any 'average Joe' off the street can gain access to a home priced at $10m. No way.

Why am I getting into the weeds on this issue? Who cares what Bernie Sanders said to Tom Price on C-SPAN during a five-hour long confirmation hearing? Because it's important. Because, if you're going to have a discussion on whether 'insurance for everybody' is really feasible or whether some offshoot of it can be rebuilt to prevent the repeal and replacement of legislation that has, to some degree, helped curb healthcare costs over the last seven years and increased the numbers of insured Americans by 20 million, then you owe it to the discussion to bring up meaningful examples. And because if you have any chance of convincing Republicans who are wavering about the repeal of the Affordable Care Act to show some non-partisan behaviour, one ought not to engage in hyperbole.

There is a seismic difference between access to health insurance, access to healthcare and actual healthcare

The point that Bernie Sanders was trying to make is that access is meaningless unless mechanisms are in place to turn that access into actual healthcare. And very often those mechanisms involve the words 'affordability'. This is where the debate makes sense. In other words, there is a seismic difference between access to health insurance, access to healthcare and actual healthcare. Those three things are very different. Are they related? Yes. Are they, in fact, closely intertwined? Yes. But they are different.

The problem is that Sanders is conflating two issues: guaranteed healthcare and the financial means (or lack thereof) to 'achieve' access to that healthcare. Go back and read his stinging retort to Price mentioned earlier in this article. First he talks about access not being consistent with a guarantee of healthcare (which is true) and then he talks about not having money even though one may have access (also true).

Based on what I've heard about Tom Price, read about his views and the senate confirmation hearings that I watched (almost from start to finish), I'm no fan of Mr Price's. And based on the verbal gymnastics that Mr Price engaged in during his confirmation hearings, there is no doubt that he is a skilled politician who may have beliefs about health policy that are inconsistent with what you and I believe to be in the best interests of the 'many' as opposed to the narrow interests of the 'few'. We know there are many reasons why healthcare fails in the traditional economic and academic sense: moral hazard, adverse selection, monopolies, indivisibilities and externalities. To name but a few. It's never just one thing. It's never just an access issue or just a money issue.

With President Trump looking to revamp and rebuild Health and Human Services, the Centers for Medicare & Medicaid Services, the Food and Drug Agency, the National Institutes of Health and re-open a conversation on the merit of preventive health services (like vaccines), let's be honest: it's going to be one heck of a long four years. And if we're going to ensure that this doesn't become a 'one small quagmire for man, one giant quagmire for science' scenario, we need to frame the issues better.